Guideline development is a learning process for everyone


By Christopher Bichakjian, MD

I’ve been involved with skin cancer treatment guidelines for quite a while, particularly through the National Comprehensive Cancer Network (NCCN), as a member of both the melanoma and non-melanoma groups. When the AAD asked me to help develop clinical guidelines for the treatment of melanoma, I gladly agreed.

The staff that guides the group through the whole process is phenomenal. The Academy’s guidelines of care are evidence based. We evaluate the best available evidence in support of clinical recommendations and grade that evidence. The Academy staff does the majority of the data collection for members and presents it in an easy-to-read format. Your job, as a member of the guideline committee, is to review all the information provided to you by the AAD staff.

While we were working on the melanoma guideline, the group met several times, sometimes in person, sometimes by phone, and followed up with emails. The process of reviewing all the research and developing the melanoma guideline was definitely eye opening!

I must admit that I enjoy the process of sitting around the table with participants from a variety of subspecialties within our field.

I learned two important things from this process. First, there are several topics that many of us believe to be quite controversial, which in reality aren’t. As part of the process, we reviewed melanoma treatment guidelines from several other countries, such as Australia and the UK. I discovered that throughout the world, there really isn’t that much controversy. It was comforting to know that, aside from minor differences, treatment guidelines are comparable throughout the world.

On the other hand, it was also humbling to be reminded that several treatment recommendations are not supported by a wealth of data, yet merely based on historical experience. While it may be generally accepted that a superficially invasive melanoma should be excised with 1 cm margins, there is no strong data to support this recommendation.  The second piece was that some things we take for granted actually have few data supporting them. I learned that there are so many things that are done a certain way simply because they’ve been done that way for decades.

I must admit that I enjoy the process of sitting around the table with participants from a variety of subspecialties within our field. It can, at times, be a real challenge to formulate a recommendation that captures the essence we are trying to achieve, yet leaves enough room for variability if warranted.

An excellent example is the biopsy technique for melanoma. One would not expect that such a straightforward recommendation would require such nuanced wording. However, it took the panel many iterations to achieve a satisfactory recommendation that included the medically critical components, while also taking into account the practical reality of care in a general dermatologist’s office.

Members who are thinking about participating in guideline development should feel encouraged to know that the guideline will relate to a disease that most everyone in our Academy treats. Every member undoubtedly knows more than they think they do and can bring valuable insight to the discussion. It’s a great way to learn more about the management of a disease that most of us may take for granted.

I greatly enjoyed the process.

Dr. Bichakjian is an associate professor of dermatology and Director of the Multidisciplinary Merkel Cell Carcinoma Program at the University of Michigan in Ann Arbor. He is a member of the AAD Melanoma Guideline Work Group and serves as chair of the AAD Melanoma Clinical Practice Assessment Tool (CPAT) Work Group. Dr. Bichakjian is also a member of the National Comprehensive Cancer Network (NCCN) Melanoma Guideline Panel and serves as chair of the NCCN Non-Melanoma Skin Cancer Panel.

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